Bronchodilators and Other Respiratory Agents

Bronchodilators and Other
Respiratory Agents
Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Drugs Affecting
the Respiratory System
• Bronchodilators
– Xanthine derivatives
– Beta-agonists
• Anticholinergics
• Antileukotriene agents
• Corticosteroids
• Mast cell stabilizers
Instructors may want to use
EIC Image #94:
Airway Restrictive Factors

Bronchodilators: Xanthine Derivatives
• Plant alkaloids: caffeine, theobromine, and

theophylline
• Only theophylline is used as a bronchodilator
Examples: aminophylline
dyphilline
oxtriphylline
theophylline (Bronkodyl, Slo-bid,
Theo-Dur,Uniphyl)

Mechanism of Action
• Increase levels of energy-producing cAMP*

• This is done competitively inhibiting
phosphodiesterase (PDE), the enzyme that
breaks down cAMP
• Result: decreased cAMP levels, smooth
muscle relaxation, bronchodilation, and
increased airflow
*cAMP = cyclic adenosine monophosphate

Drug Effects
• Cause bronchodilation by relaxing smooth muscles

of the airways.
• Result: relief of bronchospasm and greater airflow
into and out of the lungs.
• Also causes CNS stimulation.
• Also causes cardiovascular stimulation: increased
force of contraction and increased HR, resulting in
increased cardiac output and increased blood flow to
the kidneys (diuretic effect).

Therapeutic Uses
• Dilation of airways in asthmas, chronic

bronchitis, and emphysema
• Mild to moderate cases of asthma
• Adjunct agent in the management of COPD
• Adjunct therapy for the relief of pulmonary
edema and paroxysmal nocturnal edema in
left-sided heart failure
Side Effects
• Nausea, vomiting, anorexia

• Gastroesophageal reflux during sleep
• Sinus tachycardia, extrasystole, palpitations,
ventricular dysrhythmias
• Transient increased urination

Bronchodilators: Beta-Agonists
• Large group, sympathomimetics

• Used during acute phase of asthmatic
attacks
• Quickly reduce airway constriction and
restore normal airflow
• Stimulate beta2 adrenergic receptors
throughout the lungs

Three types
• Nonselective adrenergics
– Stimulate alpha1, beta1 (cardiac), and beta2 (respiratory)
receptors.
Example: epinephrine
• Nonselective beta-adrenergics
– Stimulate both beta1 and beta2 receptors.
Example: isoproterenol (Isuprel)
• Selective beta2 drugs
– Stimulate only beta2 receptors.
Example: albuterol

Mechanism of Action
• Begins at the specific receptor stimulated
• Ends with the dilation of the airways
Activation of beta2 receptors activate cAMP, which

relaxes smooth muscles of the airway and results
in bronchial dilation and increased airflow.

Therapeutic Uses
• Relief of bronchospasm, bronchial asthma,
bronchitis, and other pulmonary disease.
• Useful in treatment of acute attacks as well
as prevention.
• Used in hypotension and shock.
• Used to produce uterine relaxation to prevent
premature labor.
• Hyperkalemia—stimulates potassium to shift into
the cell.
Side Effects
Alpha-Beta Beta1 and Beta2 Beta2
(epinephrine) (isoproterenol) (albuterol)
insomnia cardiac stimulation hypotension

restlessness tremor vascular
headache
anorexia anginal pain tremor
cardiac stimulation vascular headache tremor
vascular headache

Respiratory Agents:
General Nursing Implications
• Encourage patients to take measures that
promote a generally good state of health in
order to prevent, relieve, or decrease
symptoms of COPD.
– Avoid exposure to conditions that precipitate
bronchospasms (allergens, smoking, stress, air pollutants)
– Adequate fluid intake
– Compliance with medical treatment
– Avoid excessive fatigue, heat, extremes in temperature,
caffeine

Respiratory Agents:
• Encourage patients to get prompt treatment
for flu or other illnesses, and to get
vaccinated against pneumonia or flu.
• Encourage patients to always check with
their physician before taking any other
medication, including OTC.

Respiratory Agents:
• Perform a thorough assessment before
beginning therapy, including:
– Skin color
– Baseline vital signs
– Respirations (should be <12 or >24 breaths/min)
– Respiratory assessment, including PO2
– Sputum production
– Allergies
– History of respiratory problems
– Other medications
Respiratory Agents:
• Teach patients to take bronchodilators
exactly as prescribed.
• Ensure that patients know how to use
inhalers, MDIs, and have the patients
demonstrate use of devices.
• Monitor for side effects.

Respiratory Agents:
Nursing Implications
• Monitor for therapeutic effects
– Decreased dyspnea
– Decreased wheezing, restlessness, and anxiety
– Improved respiratory patterns with return to
normal rate and quality
– Improved activity tolerance
• Decreased symptoms and increased

ease of breathing
Bronchodilators: Nursing Implications
Xanthine Derivatives
• Contraindications: history of PUD or

GI disorders
• Cautious use: cardiac disease
• Timed-release preparations should not be
crushed or chewed (causes gastric irritation)

• Report to physician:
Palpitations Nausea Vomiting
Weakness Dizziness Chest pain
Convulsions

• Be aware of drug interactions with:

cimetidine, oral contraceptives, allopurinol
• Large amounts of caffeine can have
deleterious effects.

Beta-Agonist Derivatives
• Albuterol, if used too frequently, loses its

beta2-specific actions at larger doses.
• As a result, beta1 receptors are stimulated,
causing nausea, increased anxiety,
palpitations, tremors, and increased
heart rate.

Beta-Agonist Derivatives
• Patients should take medications exactly

as prescribed, with no omissions or double
doses.
• Patients should report insomnia, jitteriness,
restlessness, palpitations, chest pain, or
any change in symptoms.

Anticholinergics:
Mechanism of Action
• Acetylcholine (ACh) causes bronchial
constriction and narrowing of the airways.
• Anticholinergics bind to the ACh receptors,
preventing ACh from binding.
• Result: bronchoconstriction is prevented,
airways dilate.

Anticholinergics
• Ipratropium bromide (Atrovent) is the only

anticholinergic used for respiratory disease.
• Slow and prolonged action
• Used to prevent bronchoconstriction
• NOT used for acute asthma exacerbations!

Anticholinergics: Side Effects
Dry mouth or throat Gastrointestinal distress

Headache Coughing
Anxiety
No known drug interactions

Antileukotrienes
• Also called leukotriene receptor antagonists

(LRTAs)
• New class of asthma medications
• Three subcategories of agents

Antileukotrienes
Currently available agents:

• montelukast (Singulair)
• zafirlukast (Accolate)
• zileuton (Zyflo)

Antileukotrienes:
Mechanism of Action
• Leukotrienes are substances released when
a trigger, such as cat hair or dust, starts a
series of chemical reactions in the body.
• Leukotrienes cause inflammation,
bronchoconstriction, and mucus production.
• Result: coughing, wheezing, shortness
of breath

Antileukotrienes:
Mechanism of Action
• Antileukotriene agents prevent leukotrienes
from attaching to receptors on cells in the
lungs and in circulation.
• Inflammation in the lungs is blocked, and
asthma symptoms are relieved.

Antileukotrienes: Drug Effects
By blocking leukotrienes:
• Prevent smooth muscle contraction of the
bronchial airways
• Decrease mucus secretion
• Prevent vascular permeability
• Decrease neutrophil and leukocyte infiltration
to the lungs, preventing inflammation

Antileukotrienes: Therapeutic Uses
• Prophylaxis and chronic treatment of asthma

in adults and children over age 12
• NOT meant for management of acute
asthmatic attacks
• Montelukast is approved for use in children
age 2 and older

Antileukotrienes: Side Effects
zileuton zafirlukast
Headache Headache
Dyspepsia Nausea
Nausea Diarrhea
Dizziness Liver dysfunction
Insomnia
Liver dysfunction
montelukast has fewer side effects

Antileukotrienes:
• Ensure that the drug is being used for
chronic management of asthma, not
acute asthma.
• Teach the patient the purpose of the therapy.
• Improvement should be seen in about
1 week.

Antileukotrienes:
• Check with physician before taking any
OTC or prescribed medications—many
drug interactions.
• Assess liver function before beginning
therapy.
• Medications should be taken every night on
a continuous schedule, even if symptoms
improve.

Corticosteroids
• Anti-inflammatory
• Used for CHRONIC asthma
• Do not relieve symptoms of acute
asthmatic attacks
• Oral or inhaled forms
• Inhaled forms reduce systemic effects
• May take several weeks before full
effects are seen
Corticosteroids:
Mechanism of Action
• Stabilize membranes of cells that release
harmful bronchoconstricting substances.
• These cells are leukocytes, or white
blood cells.
• Also increase responsiveness of bronchial
smooth muscle to beta-adrenergic
stimulation.

Inhaled Corticosteroids
• beclomethasone dipropionate
(Beclovent, Vanceril)
• triamcinolone acetonide
(Azmacort)
• dexamethasone sodium phosphate
(Decadron Phosphate Respihaler)
• flunisolide (AeroBid)

Inhaled Corticosteroids:
Therapeutic Uses
• Treatment of bronchospastic disorders
that are not controlled by conventional
bronchodilators.
• NOT considered first-line agents for
management of acute asthmatic attacks
or status asthmaticus.

Side Effects
• Pharyngeal irritation
• Coughing
• Dry mouth
• Oral fungal infections
Systemic effects are rare because of the low
doses used for inhalation therapy.

• Contraindicated in patients with psychosis,
fungal infections, AIDS, TB.
• Cautious use in patients with diabetes,
glaucoma, osteoporosis, PUD, renal
disease, CHF, edema.
• Teach patients to gargle and rinse the mouth
with water afterward to prevent the
development of oral fungal infections.

• Abruptly discontinuing these medications
can lead to serious problems.
• If discontinuing, should be weaned for a
period of 1 to 2 weeks, and only if
recommended by physician.
• REPORT any weight gain of more than 5
pounds a week or the occurrence of chest
pain.

Mast Cell Stabilizers
• cromolyn (Nasalcrom, Intal)

• nedocromil (Tilade)

Mast Cell Stabilizers
• Indirect-acting agents that prevent the

release of the various substances that
cause bronchospasm
• Stabilize the cell membranes of
inflammatory cells (mast cells, monocytes,
macrophages), thus preventing release of
harmful cellular contents
• No direct bronchodilator activity
• Used prophylactically

Mast Cell Stabilizers:
Therapeutic Uses
• Adjuncts to the overall management
of COPD
• Used solely for prophylaxis, NOT for
acute asthma attacks
• Used to prevent exercise-induced
bronchospasm
• Used to prevent bronchospasm associated
with exposure to known precipitating factors,
such as cold, dry air or allergens
Mast Cell Stabilizers: Side Effects
Coughing Taste changes

Sore throat Dizziness
Rhinitis Headache
Bronchospasm

Mast Cell Stabilizers:
• For prophylactic use only
• Contraindicated for acute exacerbations
• Not recommended for children under age 5
• Therapeutic effects may not be seen for up to
4 weeks
• Teach patients to gargle and rinse the mouth
with water afterward to minimize irritation to
the throat and oral mucosa

Bronchodilators and Other Respiratory Agents

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Bronchodilators and Other Respiratory Agents

Uploaded by

Copyright:

Available Formats

Bronchodilators and Other

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Airway Restrictive Factors

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Plant alkaloids: caffeine, theobromine, and

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Increase levels of energy-producing cAMP*

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Cause bronchodilation by relaxing smooth muscles

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Dilation of airways in asthmas, chronic

• Nausea, vomiting, anorexia

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Large group, sympathomimetics

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Activation of beta2 receptors activate cAMP, which

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

insomnia cardiac stimulation hypotension

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Decreased symptoms and increased

• Contraindications: history of PUD or

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Be aware of drug interactions with:

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Albuterol, if used too frequently, loses its

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Patients should take medications exactly

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Ipratropium bromide (Atrovent) is the only

• Slow and prolonged action

• Used to prevent bronchoconstriction

• NOT used for acute asthma exacerbations!

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Dry mouth or throat Gastrointestinal distress

No known drug interactions

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Also called leukotriene receptor antagonists

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Currently available agents:

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Prophylaxis and chronic treatment of asthma

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

montelukast has fewer side effects

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• cromolyn (Nasalcrom, Intal)

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Indirect-acting agents that prevent the